Low self-esteem in women with eating disorders and alcohol abuse as a psycho-social factor to be included in their psychotherapeutic approach.

Authors have analyzed the psychosocial peculiarities of the women from Romania who are affected by eating disorders and alcohol excessive consumption, and studied the manner of the link between these diseases and the psychosexual. 120 participants at the study (Oltenia district) were divided into 2 groups: 60 healthy women, 30 with eating disorders and 30 alcohol dependent women. In all subjects were applied the following tests: Scale for compulsive appetite (SCA) and Scale of interest for own weight, both for eating disorders, CAGE questionnaire for alcohol dependence and two scales for determining: the gender-role ambivalence (O'Neil and Caroll Scale) and the masculinity and feminity index (A. Chelcea). The results obtained in both lots of Romanian women with pathologic behavior (food and/or alcohol consumption) have indicated a low psychosexual identity versus control group but no correlation with masculinity/feminity index.


Introduction
The studies made in the last decades gathered information about feeding disturbances and substances abuse. The researchers had examined personality traits, family history biological and cultural background. Due to the fact that a large number of persons with feeding problems are women (90 -95%) must be considered the role of gender -masculinity and feminity -in the development of feeding problems and alcohol consumption.
It was suggested that both food and alcohol consumption disturbances are manifestations of an addictive type of personality. Other explanations include a) existence of a biological determination b) a dysfunctional family environment c) a fundamental struggle with a weak self-control d) insufficient abilities to cope with the stress and depression. However, all these explanation ignores some other aspects of social and cultural context in which food and alcohol intake problems occur The study of psychosexual identity as well as the womanhood and manhood coefficient is another way to examine this context In the same time, undertaking a psychosexual identity is tight related to self-acceptance, a component of the self with a wider conceptual sphere including other personality attributes: positives (qualities) and negatives (flaws).
Women with gender-role attributes feebly defined are much more probable to have a slender selfacceptance thus making them more vulnerable to problems involving feeding and alcohol consumption.
Defining self-acceptance/ self-esteem (two notions not entirely overlapping) Crisp and Turner (2008) deemed that being an evaluative component of the selfdesignated to establish our rank among the others including towards the standards / role models deemed being positive or negative. Self-acceptance nuances the evaluation of self-image (bringing into light of conscience of own thoughts, emotions, behaviors) in axiological way, representing also an attitude of being or not in agreement with that image.
Self-acceptance refers to the adaptive role of self and it is expressed trough its continuous tendency to diminish the tension therefore ensuring the equilibrium and peace. Self-acceptance has as main goal gaining the gratification on imaginative or symbolic level. Self acceptance ponder itself in a good positive opinion being compatible with a person full of trust and worth, a person who take both praises and disapprovals in an objective manner. Attitude of a positive self-image person it is based on inner values and who accepts the consequences occurring from own behaviors.
A low degree of self-acceptance is translated in a negative opinion towards self and the conviction that others too have the same opinion.
That independent variable could have following levels: a low degree of self-acceptance, a medium or normal degree, and a high degree of self-acceptance.
Self-acceptance plays a key role in development of a personality and a self and it is a major component of our emotional health If both Kahn and Singha had discovered a positive correlation between low self esteem and feeding and alcohol intake disorders, then Striegel -Moore (1993) opinionate that stress induced by the image of own body could too determinates women to involve in abusive behaviors like excess drinking or food disorders (bulimia anorexia obesity). In other words, low self-esteem could be both result and cause of such behaviors. The present work has as intention to analyze these personality traits from perspective of considering personality as a crucial factor in genesis of feeding disorders and alcoholism.

Theoretical Objectives
1. Discovering the influence of the social cultural environment in the rate of feeding disorders at women and more specific if under influence of social and cultural environment some people are more susceptible than others to feeding disorders and alcoholism. The purpose of this work is to see if in our country also the cultural pressure could have a negative effect on selfesteem thus initiating and maintaining feeding and substance abuse problems. 2. Determining the relation between selfacceptance and problem related to food and alcohol problems.

Practical Objectives
1. If we determine that women with alcohol and food intake problems are influenced by cultural pressure exerted on them and if we also determine the measure and the way in which such pressures are manifested would be easier to prevent and treat such problems. 2. The main practical objective of this work is related to fact that once we demonstrated the relation between alcohol and food abuse problems at women and social cultural influences involved in self esteem we could develop new programs of prevention and treatment

Motivation
Why feeding related disorders at women? We choose the study of feeding related disorders because in our country also the number of people affected by problems like obesity, bulimia, strict and severe diets is in a continuous rising and studies upon Romanian population are rather scarce and the great majority the population affected by over mentioned problems are women.
Why alcoholism in women?
The motivation of choosing studying alcoholism at women holds with the neglecting of this problem in the past. Because the number of persons affected by alcoholism is higher among men the problem of women's alcoholism was not enough studied and maybe therefore the number of women involved in alcohol related problem is raising in real life.
Therewith prevention and treatment programs regarding alcoholism in our country and not only, doesn't take account of clinical, psychological and social features specific to women with an alcohol related problem and thus the healing is more difficult to attain.
This study is motivated by the willing of a differentiate approach to alcoholism at women, and that approach should be regarded in the wider context of alcoholic woman's psychology

General hypothesis
We suppose that women who manifest feeding and alcohol consumption problems will be low in selfacceptance Independent variable: disorders of feeding and alcohol consumption (TAA) Dependent Variable: self-acceptance In a future work, we will analyze the link between eating and alcohol problems and psychosexual identity undertaking considering some other dependent variables such as gender role ambivalence, femininity and masculinity quotient.

Samples
In the present experiment 120 women participated, 60 of them from general population witness group, and 60 women with alcohol and eating problems of which 30 with eating problems such as bulimia, obesity and harsh diets and 30 women with alcohol problems. It is owed to large number of items and investigations required, while the size of the work group is so small.
All subjects of this experiment are from urban environment, more precisely from Bucharest and Ramnicu Valcea.
Control group subjects without eating or alcohol problems were pupils and teachers from several high schools: «Alexandru Lahovari» Economic, National College, «Mircea cel Bătrân» National College, and also students from UMF -University of Medicine and Pharmacy -dentistry section.
All of the 120 participant subjects are feminine gender with ages between 18 and 45, Romanian citizenship, Romanian nationals, orthodox confession, permanent inhabitants in those two cities Bucharest and Ramnicu Valcea.
Subjects were tested each Friday of the month between 10 and 13 AM being administrated all the tests consequently.
What about subjects in work group they were called by their psychiatry medic ant they were explained about the participation at a study and the answers done at the papers and questionnaires have no relevance and consequences at all upon their cure, or hospital situation and also there are no good or bad answers at all and no time limit.
All participant subjects, including hospital patients were quite cooperative

Apparatus (Materials, Scales, Instruments)
What about the apparatus used in the present experiment we used as materials: paper, pencil, (instruments and answering sheet) as well as chair and desk used during tests by subjects to respond to tests items.
Regarding the instruments of psychological testing that we used those were compulsive appetite scale, Scale regarding diet and own weight preoccupation and Cage questionnaire, Scale of self-acceptance. That scale is frequently used today in the whole world as well as for research and also in medical psychology and psychiatry to measure and characterize in a multi axial way the self esteem and self acceptance.
Low scores (0 -110) express a low self acceptance. Such a score could be translated as a negative image on own self and the feeling that the others have the same bad image on that person.
Medium scores (111 -150) reveals a normal level of self acceptance; however that means ups and downs could occur from a day to another depending on the specific of the situation and therefore a better or less better impression on own self appears on daily basis.
High scores (151 -180) show us how that person is full of confidence and trust in his/her own worth. The others may see that person being very affable because he/she accepts both praises and critics in an objective manner. Attitude of such a person is based upon inner values and accepting consequences resulting from own behaviors.

Method
The present research has the purpose to demonstrate the existence of a correlation between alcohol and eating disorders (TAA) on a side and selfacceptance on another, following that in other work to be analyzed the results of correlation between psychosexual identity and masculinity and femininity quotient. Independent variable is constituted by the problems related to eating and drinking. About eating, we have in view women diagnosed with bulimia, anorexia, obesity and harsh, punishing diets. What about drinking problems; in view were women with dependency and frequent abuse of alcohol.
In all hypotheses, independent variable is the same: the women with feeding and drinking problems. Instead, the dependent variable takes different values.
In the first hypothesis regarding correlation between eating disorders and self-acceptance, the selfacceptance is the dependent variable.
To testing hypotheses, we gathered three experimental groups.
Experimental group 1 witness group composed by the 60 women without drinking and eating disorders Experimental group 2 work group 1 composed by those 30 women with eating disorders Experimental group 3 work group 2 composed by the rest of 30 women diagnosed with drinking problems In the first general hypothesis the result obtained at self-acceptance test by control group and work group 1 were compared. Because admittance in those two work groups was made upon positive results at those two scales regarding eating problems (1. compulsive appetite 2. diet and weight control preoccupation) on a side and CAGE questionnaire regarding overdrinking on the other side, only a comparative display of the results obtained at the Berger scale of self acceptance by both groups will be made.

Results
The result were corroborated with psychiatrist diagnoses and they are displayed at tables no 1 and 2 1. What about checking the authenticity of the first hypothesis

General hypothesis 1
If women present eating disorders then they will have a lower self-acceptance. To verify this we use the self-acceptance scale applied to all subjects. The results may vary from 0 pts. to 180 pts.
The results of the subjects entered in the following ranges of values

Control group -95 -143 Work groups 1, 2 -59-126
To test the hypothesis we use t test -student test -for independent two-sample The control group was the first sample and the two workgroups put together were the second sample. Test of self acceptance were applied to both samples ant the results are shown in diagram1 In order that Student's t test to be applied we need a normal distribution, therefore indices of skewness and kurtosis, were calculated. The value of those two indices must be between -1 +1 as a condition for the test to be applied. The result being in the range the test could be applied on those independent two samples.
As a result of t test applied on the two independent samples (t =7,992) we obtained a significance threshold equal to 0,007. The value of this threshold is very important to determine some correlations between the two variables from hypothesis. Our threshold value of 0,007 < 0,05 indicates that is a relation between the variables. Mean value of self acceptance quotient is significantly higher in control group (m=117,37) than the mean value obtained in those two work groups put together (m=91,95). It is obvious that first value, Graph 1 Discussions 1. The present research gives us the opportunity to collate a sample constituted by women without eating and drinking problems -control group -with a sample made by women with eating disturbances to see if there are significant differences between those two groups regarding self acceptance Data obtained by applying statistical tests indicate the existence of a significant difference toward selfacceptance 2. To determine the levels of self-acceptance we had applied the Scale of self-acceptance to all subjects of this research. The starting point being the hypothesis of lower self esteem at women with eating disorders 3. Analyzing the results presented earlier we can see that the great number of problems free women are situated in the medium range value of self acceptance quotient while a great number of women who have feeding and alcohol problems are situated in the low range of self esteem quotient.

Previous researches -Krahn and Singha, as well as
Striegel Moore -testify the presence of a negative self image to women with eating problems who use adjectives like " grotesque", "fat" or "disgusting" and frequently bodily image have no correspondence in reality, hereby their body weight being in normal limits sees herself as being massively overweight 5. Also to a great number of TAA women that we studied there were noticed affective symptoms including dysphoria, self depreciation, loss of focus, lack of interest, hopelessness, sleep disorders, suicidal thoughts. Those aspects support the connection between affective and eating disorders 6. Importance of studying the self image, lowered at women with TAA -according to our study-resides in fact that the psychologist solicited to treat the addictive behaviors of those women patients, finds an highly effective action point to begin with his psychotherapeutic and also situational actions designated to cut off the vicious circle like TAA- negative self image  TAA 7. The psychotherapist should investigate the causesothers than TAA effect -meant to affect AS at women under psychological or psychopharmacology interventions.
The psychotherapist should know the TAA pacient's personality and her biographic context, first of all the relations between the patient and the ones from "ecological niche" (Willi) in which they exist, meaning the relationships with the close ones (couples, family, colleagues).
Besides psychosocial factors annihilation, the psychotherapist should take into consideration other variables from social psychology domain, capable of reconstruct self-esteem to any individual -this is also applicable in women with low TAA and AS.
We should have in mind that self-esteem is not something rigid, inextensible and incapable of changesit can vary depending on life changing situations (Crisp & Tuner). 8. There were several cases in which the couple's relationship might have influenced the TAA etiopatogenia.
The persistency of this kind of relation could be the starting point for a low AS or the cause of TAA -these could be triggered by affective trauma, depression.
Another vicious circle closes when the "prosecutor" (the partner) is accusing the guilty paircaused trap addictive behavior -the effects of nutritional imbalance, manifested in the physical aspects or the negative social consequences of altered relationships with entourage.
This kind of partner could encourage (especially in alcoholism) the practice of this fault, as long as excessive eating, but then could became critical accusing the partner (while having already low AS) -unsightly the consequences -these could cause breaking the couple and then to a even lower AS of the patient.
The psychotherapist, trained to deal with this kind of situations could try to remove the patient from the influence of non-corresponding partner or could try to build and improve the relationship between them, especially when talking about married couples. 9. Compensating low self-esteem could be done through increasing, on psychotherapist advice, the social interaction of TAA patients (these is applicable for the ones already under recovery program), as per Steele theory ("self affirmation therapy") who considers that when the self-esteem is low or threaten, the individual will have a compensatory behavior, due to reveal some real qualities, "un-exposed" before. 10. Most of the patients with low self-esteem tend to isolate and we must fight against this aspect. TAA consequences (physical and behavioral) tends to underline the tendency to social retraction.
To the satisfaction of each person's need for affiliation (Linton), the concept "including other in the self" (Aron et al.-1992) it refers to the human tendency to share with their loved ones everything that feels goodusual reserved for themselves.
The psychotherapist could exploit in favor of low AS patients this tendency, encouraging affective investment towards people (especially children and trusted friends), pets etc;, having the real chance for the studied patients to recover their low AS and heal TAA (of course adopting also others terapeutical measures). 11. On the other side, on virtue of the social identity of an individual, tends to maintain himself within the membership group even though in here he has a lower status, which can generate a low self-esteem.
Raising self-esteem and self-acceptance could be done spontaneously (but not always) in two ways: -Social affirmation -Dissociation -from personal traits, group specific -of those which are non-essential, which he has more than the rest of the group ("Disidentity" -Tajfel & Tuner) It is not sure of the TAA women and with low self-esteem use these spontaneous mechanism of resolving the self-esteem gap between the group members, but it is sure that a benefic role can be played both by satisfying the need of group affiliation and by the possibility of adjusting the self-esteem through the affiliation.
Therefore, taking into consideration the above evidence, the psychotherapist can insist on the necessity of TAA women with low self-esteem to use not only spontaneously but also "controlled" by the therapist of those possibilities to use social contacts. We can speak about a "genuine therapeutic plot" capable of raising selfesteem and correcting the addictive behavior (Sedikides and Gregg -2002). 12. Must not be omitted the fact that not all the persons with eating and weight problems are accompanied by a low self esteem and a negative self image, especially when those trait are moderate and coexist with immunogenic traits of personality such as optimism, robustness well and thoroughly expressed ( « Jovials obesity" -Iamandescu).

Synopsys of conclusions
Previous researches as well as our study proves that it is a strong connection between the eating and drinking disorders -TAA -studied together and self acceptance. What is less known is in what measure the negative self-image and a low self-esteem are causes or effects of feeding and drinking problems? Furthermore, there are the following important aspects to clarify the existence and type of correlations between various affective disorders and eating and drinking disorders and those correlations in the specific social cultural environment and conditions of Romania.
In the frame of this study, we have had in view to track down the psychological and social specificity of alcoholism and eating related disorders at women from Romania.
The present study has as aim to demonstrate the relation between self-acceptance and self-image and eating and drinking related disorders at 120 subjects. The allotment was as following: a work group of 60 women, 30 of them with eating disorders, 30 with alcohol related problems, an witness group of 60 women from the rest of population without problems related to eating and drinking.
The tests applied to diagnose TAA were the following: "compulsive appetite scale", "scale regarding diets and own weight preoccupation", "Cage questionnaire" about drinking problems and "Berger scale of self acceptance" The results of first three scales were collated to the result of the last scale -Berger -applied to all 80 subjects.
Following analysis and data interpretation results that low self acceptance and a negative self image are characteristics of women with TAA alcohol and eating disorders